We propose a collaborative, mix-method study of the Minnesota Return to Community Program (RCP). RCP is an innovative state-level intervention that promotes transition of nursing home residents to the community. It concentrates on individuals who wish to leave the nursing home, are not yet Medicaid eligible, and whose stay in the nursing home is between 60 and 90 days. These are individuals who risk a long-term nursing home stay and conversion to Medicaid. The RCP staff members give residents and family caregivers options counseling and transition planning, assist them in making the transition, and monitors their situation while in the community through follow-up assessments every 90 days. The program attempts to avoid unnecessary hospitalizations or nursing home re-admission. Also, the RTC uses a variety of strategies to engage nursing homes in the transition process. Our study will achieve these aims. 1. Evaluate the RCP's outcomes in increasing resident transitions to the community, reducing nursing home utilization, delaying individual conversions to Medicaid, avoiding unintended negative consequences for transitioned residents (e.g., increased hospital admissions, ED use, or nursing home readmissions) and achieving Medicaid savings. 2. Assess the RCP' program processes for promoting and sustaining transitions: (a) ADRC staff's approaches to resident targeting, counseling, transition planning, and follow-up; (b) nursing home engagement in the program and deployment of nursing-home staff toward transition goals; (c) transitioned and family caregiver view's of the program. 3. Appl evaluation findings to program improvement in an iterative fashion throughout the 3 years of the study. 4. Disseminate study findings to state Medicaid programs, ADRCs, nursing facilities and other long-term care settings to assist them in developing effective transition programs. The study responds to AHRQ's Health Services and Research Demonstration and Dissemination Grants (R18) RFA. A multidisciplinary research team from Indiana University (IU) and University of Minnesota (UMN) having extensive long-term care experience and in- depth knowledge of the Minnesota long-term care system will carry out the study using a mixture of quantitative and qualitative methods. They will collaborate with colleagues at the Minnesota Department of Human Services (DHS) and BoA who designed and administer Return to Community Program.